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Traumatic Brain Injury

Number 1 killer of children and

young adults

Review of SCI Lecture

Statistics • MVAs cause 50% of all head injuries

• Falls = 21%

• Violence = 12%

• Sports = 10%

• Male > Female

• Ave. age at time of injury between 15 & 24

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Prevention

• ...The only true “cure” for TBI

• Preventive measures

– Wearing seat belts & bike helmets

– responsible alcohol consumption (no drinking

and driving)

– Use of proper protective equipment in athletics

Classifications

• Head injuries classified according to the

Glasgow Coma Scale:

– mild

– moderate

– severe

can also be classified according to

• open vs. closed

• high-velocity vs. low velocity impact

• diffuse vs. focal

3 Factors Affecting Outcome

• 1. Premorbid Status

• 2. Primary Injury: the amount of immediate

damage to the brain from the impact of the

brain injury

• 3. Secondary Injury: the cumulative effect

of secondary brain damage produced by

systemic and intracranial mechanisms that

occur after the initial injury

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3 Factors Affecting Outcome

• 1. Premorbid Status

– normal vs. altered (enchephalitis, CVA)

• 2. Primary Injury: depends on the nature,

direction, and magnitude of forces applied

to the brain, skull, and body

Factors Affecting Outcome • 3. Secondary injury: following TBI,

numerous conditions decrease the energy

supply to the brain, causing secondary

injury to the brain

– Hypoxic-ischemic injury (HII)

– Intracranial hematomas

– Intracranial infection, cerebral artery

vasospasm, tumors, obstructive hydrocephalus,

post-traumatic epilepsy

Types of Primary Injury – local brain damage: injury is localized to the

area of the brain underlying the site of impact

• produces predictable neurologic signs

– Coup-contrecoup injuries: a severe blow to the

head damages under the site of impact and

directly opposite the site due to the brain

bouncing within the skull

– polar brain damage: occurs when the head is

accelerated and decelerated (MVA)

• brain impacts on the skull

– Diffuse axonal injury (DAI)

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Coup-Contrecoup

Clinical Rating Scales

• Glasgow Coma Scale (GCS): documents the

level of consciousness and defines the

severity of the injury

– relates consciousness to motor response, verbal

response, and eye opening

– Has been extensively tested for inter and intra

rater reliability and is highly reliable

– Patients scoring an 8 or less are identified as

having coma & severe brain injuries

– Scores 9-12 = moderate brain injuries

– Scores 13-15 = mild brain injuries

– (Martin & Kessler, Table 11-1, p353)

Clinical Rating Scales

• Rancho Los Amigos Level of Cognitive

Functioning (LOCF): outlines a predictable

sequence of cognitive and behavioral

recovery seen in pts with TBI

• Rappaport’s Disability Rating Scale (DRS)

• Glasgow Outcome Scale (GOS)

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Diagnostic Procedures • EEG

• CT

• MRI

• Cerebral Blood Flow Mapping

– PET

Interdisciplinary team – Patient & family

– PT, OT, SLP

– MD, rehab nurse, case manager/team

coordinator

– MSW

– neuropsychologist

Acute Management • PT is indicated in early management of the

pt with moderate or severe head injury

• Initial rx revolves around prevention of

complications:

– respiratory distress

– contracture development

– skin breakdown

– PROM; splinting; passive standing in tilt table

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Acute Management

• Functional mobility training: begins when

the pt’s medical status is stable

– increase upright standing tolerance

– increase pt’s active movement capabilities

– sensory stimulation (reviewed later)

– **always check in with the RN because a pt’s

status can change dramatically in a short period

of time and alerts the RN that PT is beginning

which can alter the pt’s status (increased vital

signs)**

Direct Impairments

• 1. Cognitive

• 2. Neuromuscular

• 3. Visual / perceptual

• 4. Swallowing

• 5. Behavioral

• 6. Communication

Direct Impairments

• 1. Cognitive

– Altered Level of Consciousness

– Coma: defined as “not obeying commands, not

uttering words, and not opening the eyes.” &

sometimes the GCS score is used to define

coma, a score of ______ defines a coma

– Vegetative: decreased level of awareness with

intact eye opening and sleep-awake cycles, but

no ability to follow commands or speak

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Direct Impairments

• 2. Neuromuscular

– Often present with abnormal tone

• From spasticity that affects entire body & function

to low tone of indiv muscle groups that does not

impact function

– Proprioception & kinesthesia are common

sensory deficits

– May see balance deficits, nystagmus,

hemiparesis, ataxia, vestibular loss, visual

deficits, etc

Direct Impairments

• 3. Visual/Perceptual Impairments

– Hemianopsia

– Blindness

– Spatial neglect

– Apraxia

– Somatagnosia

– Right-left discrimination

Direct Impairments

• 4. Swallowing

– Dysphagia is very common

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Direct Impairments

• 5. Behavioral Deficits

– Are the most enduring & socially disabling of

any of the impairments commonly seen after

TBI

– Patient will have a behavioral program created

by the neuropsychologist

– Sexual disinhibition, emotional disinhibition,

apathy, aggressive disinhibition, low frustration

tolerance & depression often lead to a life of

seclusion & loneliness

Direct Impairments

• 6. Communication

– Expressive or receptive aphasia

– Reading comprehension

– Written expression

– Language skills deficits

– dysarthria

Indirect Impairments

• Contractures

• mobility

• skin breakdown

• heterotropic

ossification

• decreased endurance

• Infection

• pneumonia

• impaired speech

secondary to trach

• DVT

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Management Based on Cognitive

Level

• Because the cognitive level of the pt

determines the extent to which s/he can

be actively involved in the treatment, the

organization of PT treatment information

is built around the pt’s cognitive level

• Treatment considerations for pts in

Rancho Los Amigos levels (LOCF)...

LOCF • 1. No response

• 2. Generalized response

• 3. Localized response

• 4. Confused - agitated

• 5. Confused - inappropriate

• 6. Confused - appropriate

• 7. Automatic - appropriate

• 8. Purposeful - appropriate

Low Level Management

• LOCF I - III

• Evaluation: PROM, spontaneous activity,

response to stimulation, muscle tone and

reflexes, and the presence of gross motor

skills (postural reactions)

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Low Level Management

• Goals: prevent any complications

(contractures, decubiti) and increase the pt’s

level of interaction with the environment

(by encouraging active movement and

response to stimulation)

Low Level Management

(Treatment) • PROM: can be reasonably aggressive, but

must use caution

• Sensory stimulation: used for arousal and

to elicit movement. Must watch for the

response to the stimulation (can manifest as

changes in HR, RR, BP or eye movement,

facial grimacing, head turning,

vocalizations). Must note the following:

Low Level Management

(Treatment)

– latency: time delay between stimulus and

response

– consistency: how many times (within a set

number of reps) does a pt respond to the same

stimulus

– intensity: the response should be proportional

to the stimulation

– duration: brief form of stimuli should result in

brief forms of response

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Low Level Management

(Treatment)

– visual stimulation: utilize pictures of family

and friends; systematically stimulate all areas of

the visual field (account for visual field

deficits); document visual attentiveness and

tracking

– olfactory stimulation: provided by placing

scents under a pts nose for 10 - 15 seconds

during quiet breathing (best results from the

pt’s own favorite smells)

– tactile stimulation: provided during functional

activities (turning, bathing, dressing)

Low Level Management

(Treatment)

– vestibular stimulation: provided by C/S

ROM, rolling on a mat, rocking, or pushing

the pt in a wc.

– auditory stimulus: use normal

conversational tone, discuss topics that have

meaning to the pt. Avoid background noise

(it competes with meaningful stimuli)

Low Level Management

(Treatment)

• Positioning:

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Mid-Level Management

• LOCF IV: present very specific challenges

because these pts are in a confused and

agitated state

– Evaluation: in addition to those areas evaluated

in LOCF I - III, must assess functional tasks

(ambulation, basic transfers)

– Goals: increase or maintain ROM, prevent

deconditioning, improve response to simple

commands, prevent outbursts through a highly

structured environment

Mid-Level Management

– Special considerations:

• remember the pt is confused: the pt should be seen

by the same person at the same time, in the same

place every day; establishes a routine

• expect no carryover: teaching new skills is

UNREALISTIC

• model calm behavior

• be prepared with numerous activities

• offer options: “would you rather play ball or go for a

walk?”

• expect egocentricity: the pt will tend to only think

about him or herself.

Mid-Level Management – Treatment: ROM, gross motor activity

• **attempt to improve endurance rather than progress

to more challenging tasks (because that requires new

learning)**

• may need to employ creative techniques: “come

walk with me to get the cards” instead of “let’s take

a walk”

• attention deficits are addressed through activity

participation (pt attention can gradually improve

during activities)

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Mid-Level Management

• LOCF V - VI: these pts are confused but no

longer agitated; can follow simple

commands but if demands increase and

structure decreases, performance

diminishes; carryover is present but best for

relearned activities; new learning very

limited

Mid-Level Management – Evaluation: usually possible to perform a

formal eval but should be concise with simple

instructions

– Goals: increase pt participation in program;

increase/maintain ROM; increase conditioning;

treatment of any motor deficit (i.e. hemiparesis,

peripheral nerve injury, etc)

Mid-Level Management – Treatment: should…

• maintain structure: pt performance still depends on it

• emphasize safety

• keep instructions to a minimum: too much can

confuse and irritate the pt

• use physical props to improve compliance: timer so pt

has concrete sense of time; videotape of performance

so pt can view that performance realistically

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High-Level Management

• LOCF VII - VIII

• Usually during this stage that the pt is

D/C’d from inpatient facilities

• Prior to D/C, it is necessary to wean the pt

from the structure that was critical in early

rehab

– the pt has some insight now into his/her

strengths and weaknesses and should be

involved in decision making as much as

possible

High-Level Management

• Goals: assist the pt in integrating the

cognitive, physical, and emotional skills

that are necessary to function in the real

world.

– judgement, problem solving, planning are

emphasized

High-Level Management

• Treatment: focuses on community skills,

social skills, ADL

• Judgement, problem solving, and planning

are emphasized

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High-Level Management

– these pts will require vocational and driving

services to reach their optimal functional level

– PT services at this point usually are for specific

motor disorders and do not differ significantly

from the types of therapy provided to pts

without cognitive dysfunction.

– ** overall goal is for the pt to function

optimally in society **

Issues That Cross All Levels

• ROM: decreases occur due to several reasons

– prolonged bed rest; decreased consciousness,

spasticity, lack of voluntary movement

– Treatments for spasticity include oral meds, nerve

and motor point blocks, serial casting, positioning

systems

Issues That Cross All Levels

• Mobility: must take the cognitive issues into

consideration

early rolling (low-level); supervised wc propulsion

(mid-level); assisted ambulation; power wc

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Issues That Cross All Levels

• Documentation: must precisely record

the physical and cognitive functioning.

– For example, a pt may have a high physical

functioning level but require close

supervision due to poor safety awareness.

This should not be documented as

independent physical capacity because of the

cognitive impairment

Issues That Cross All Levels

• Adaptive equipment

– wheelchair: manual or power; variety of

controls

– advanced computer technology

• simple letter board for communication

• or complex environmental control unit

Issues That Cross All Levels

• Outcome prediction: our ability to predict

outcomes is very limited due to the extreme

complexities of the issues related to head

injury

– being able to live independently, earn an

income, manage daily activities and affairs are

the outcomes that survivors strive for

• many can reach this level

• many cannot

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Integrating Physical and Cognitive

Components of a Task into

Treatment Interventions • Cognitive and Behavioral Impairments:

– Disorientation: calendar, memory book

– Attention deficits: stopwatch or timer

– Memory deficits: memory book, computerized

schedule books, watches and pillboxes

– Problem-solving deficits: create situations that

alert to safety; route finding tasks, obstacle

courses

Integrating Physical and Cognitive

Components of a Task into

Treatment Interventions

– Behavioral deficits: consistent schedule,

structured environment, keeping patient

occupied

– Aggressive behaviors

– Motor deficits: high level balance activities,

use of movable surfaces

Treatment Guidelines for Behavioral

Impairments

• Agitated patient

– remove all jewelry

– remove anything from around your neck -

ID tag, necklaces, ties

– see the patient regardless - if they are too

agitated to treat, then walk the halls with

them or provide some quiet supervision

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Treatment Guidelines – Throw your goals out the window!! #1 goal is

SAFETY - for you and the patient

– call for help if you need it

– talk normally - listen to yourself. Talking in a

calm and soothing voice does not mean a sing-

song voice. Be natural - joke around if it helps,

be matter of fact if it helps, but don’t baby these

folks

Treatment Guidelines

• Don’t push it - if the patient refuses and it

seems like pushing them will agitate them,

stop and take a break

Treatment Guidelines • Verbal aggression

– remain calm and concrete

– be “with” the patient

– be aware

– empathize

– key words and verbal praise

– give space

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Treatment Guidelines – Watch body language and voice tone; calm

non-threatening nonconfrontive

– remember the client will process information

more slowly, less accurately

– don’t attempt to teach or counsel until de-

escalated

– DO NOT argue, threaten, get angry, get

aggressive, bend or discard rules

Treatment Guidelines – DO NOT get into a power struggle or make

false promises

– DO redirect without going off the subject

– use humor where appropriate

– “listen”

– lessen stimulus: get patient to leave area or get

others to leave

Treatment Guidelines – Offer help: “what can I do to help?”; “let me

help you with…”

– provide orientation information

_ reinforce limits

– FOLLOW THE PLAN

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Wrap up Today’s Lecture

Questions???

• O’Sullivan, S.B. & Schmitz, T.J., (2000),

Physical Rehabilitation, 4th Ed., F.A. Davis

Company: Philadelphia.